Historical and Contextual Considerations for Clients
Siobhan L. Healy
This paper discusses four cases in total, two from the perspective of a psychologist in private practice and two from the perspective of a school psychologist.
First, we will be covering two clients who visited Dr. Goldstein’s private practice:
Client #1: Brian, a 28 year old, married father of a two year old daughter and a six month old infant son, is expressing a feeling of unhappiness. He states that he is miserable, making everyone around him miserable.
Client #2: Cindy, a 41 year old, recently divorced woman without children and high school education is not able to relax and worries about something all the time. She experiences a feeling of “going crazy”.
Next, we will be discussing two clients Dr. Venneman, the school psychologist, is covering:
Client #1: Rosie, a 7-year-old second-grader from an intact family has recently moved into the school district and was referred for experiencing academic difficulties concerning reading and writing, as well as social difficulties with her classmates.
Client #2: Marco, a 17 year old high school student was referred for failing grades and refusal to follow course sequences. He is considering dropping out of school.
The hypothesis for this paper is, that, when clinicians are able to gather enough information about their clients’ history and weave together pertinent data to get a clear picture of each case, they will be able to use the correct assessment in order to design a treatment plan.
According to Groth-Marnat, the evaluation of the referral question in each case is of great importance. An inaccurate clarification of a problem can result in practical limitations of psychological evaluations. It is the clinicians’ responsibility to provide useful information and to clarify the requests they receive, and each clinician is aware of the value and the limitations of psychological tests. Furthermore, clinicians should not assume that requests for evaluation and referrals are adequately described or elaborated on. In fact, clinicians may need to uproot unspoken expectations of clients and uncover interpersonal relationships and hidden agendas. Limitations of psychological tests need to be explained to clients and the clinician is required to fully understand the vocabulary, dynamics, referral setting, and conceptual model (Groth-Marnat, 2003).
Because clinicians are rarely asked to provide a general or global assessment, but are instead expected to answer specific questions, they need to address these questions and should contact the source of the referral at various stages in the assessment process. In an educational evaluation, such as in Rosie’s and Marco’s case, the school psychologist should observe the student in the classroom environment. The information gathered from such an observation should then be relayed back to the source of the referral (school) in order to get further clarification and, possibly, a modification of the initial referral question (Groth-Marnat, 2003).
After gaining insight into the referral question, clinicians should proceed with the collection of information. A variety of sources may be used for this purpose, such as personal history, interview data, behavioral observations, and test scores. Furthermore, clinicians could obtain any previous psychological evaluations, medical records, police reports, school records, or they could discuss the current issues with the client and/or with parents or teachers (Groth-Marnat, 2003). For example, Dr. Goldstein could ask his client, Brian, the 28 year old father of two small children, a few background questions, such as, “when did you first experience the feeling of unhappiness and what exactly do you do to make everyone around you miserable”, or “how was your marriage before the birth of your children”, “what may be additional stress factors besides the overwhelming task of having two young children”, and “how is your social life”?
Furthermore, Dr. Goldstein should explore any possible medical reasons for Brian’s “unhappiness”. Once the clinician has ruled out certain factors that may be contributing to Brian’s condition, he may be able to pinpoint the cause of his unhappiness and determine that Brian is simply and temporarily overwhelmed by the addition of a new baby to an already stressful life. After all, additionally to having to go to work to financially support a family of four, Brian is most likely sleep deprived due to his infant son’s irregular sleep pattern. Ultimately, Brian’s wife and daughter may be placing unreasonable demands on him by asking for more help and attention. Most likely this phase will pass and the clinician will be able to design a solid assessment and treatment plan.
Dr. Goldstein’s second case of Cindy, the 41 year old, divorced female, may be a complex one to examine. Once again, Dr. Goldstein should ask Cindy questions such as “what were the reasons for your recent divorce”, and “when did you first experience the feeling of “going crazy” and how does it present”, “what kind of worries are the most prevalent and what have you tried to do in order to relax”? After ruling out a medical problem, the clinician should examine Cindy’s situation carefully, as it sounds like she may be suffering from anxiety and depression due to her recent divorce. After the divorce, she may have also lost common friends she shared with her partner. The divorce may have left her financially and emotionally drained and she may be going through a midlife crisis. In cases like that, the potential for substance abuse as a coping mechanism can be high. With detailed information about Cindy’s background, Dr. Goldstein should be able to create a thorough assessment and a feasible treatment plan.
In the case of Rosie, the 7-year-old second-grader from an intact family who recently moved to a new school district, the school psychologist, Dr. Venneman, should obtain any and all school and medical records and he should gather as much information from Rosie’s parents and current and former teachers (or principals). Dr. Venneman should explore whether Rosie had any academic issues in her former school. She may have to get an eye exam to rule out a vision problem since her decreasing performance involves reading and writing. After ruling out any medical problems, Dr. Venneman should find out if Rosie may be missing her old friends and social activities. He should ask parents and teachers questions such as “has she made any friends at all yet”, or “is she still involved in the sports activities that she used to enjoy”? It is very likely that Rosie is just experiencing a temporary loss of a sense of stability (of a predictable environment and routine) and the loss of her friends due to the move. Once she is used to her new situation, she will most likely be able to adapt, make new friends, and catch up with school work.
In the case of Marco, the 17 year old high school student who is considering dropping out of school, Dr. Venneman may have to explore his school and police records and conduct interviews with his family and teachers. After ruling out a medical condition or a possible criminal past, the clinician should ask Marco and everyone concerned a number of questions, such as “how long has the lack of interest in school work persisted and what was done to intervene”, “what are his peers like”, and “what does Marco want for his future”? Fortunately, Marco is a short time away from graduating from high school and the clinician should put emphasis on finding a quick and solid solution to jump-start Marco’s motivation.
In all of these cases, it is important to realize that any tests themselves are just one tool (or source) for gathering data. Each case history is of importance as it provides the clinician a context for understanding each client’s current issue and with this knowledge the test scores become meaningful. A number of ethical guidelines have emerged for conducting formal assessments, ensuring “that appropriate professional relationships and procedures are developed and maintained” (Groth-Marnat, 2003, p.48).
When assessing all of the above clients, the clinician must carefully consider what constitutes his or her ideal practice. There will always be difficulties involving assessment procedures. The main issues are the “use of tests in inappropriate contexts, confidentiality, cultural bias, invasion of privacy, and the continued use of tests that are inadequately validated” (Groth-Marnat, 2003, p.48); consequently, this has resulted in many restrictions as to the use of certain tests, increased skepticism, and a greater need for clarification within regarding ethical standards within the field of psychology (Groth-Marnat, 2003). As in Rosie’s and Marco’s case, the clinician would be concerned about dealing with minors, especially if one was diagnosed with a disability, and should obtain consent to perform the assessments through a parent or legal guardian.
As described by Steege & Watson (2013) “when information is systematically collected and analyzed for the express purpose of determining behavioral function and the development of a BIP, it should be considered an evaluation and parental permission obtained” (p.34). Furthermore, it would be unethical of Dr. Goldstein, for example, to reveal information about Brian or Cindy to others, unless the clients are posing a risk to themselves or others (such as a threat of suicide or homicide) (Steege & Watson, 2013).
In the case of Cindy, Dr. Goldstein could begin with a semi-structured interview format and list a sequence of questions that he would like to ask her. The first series of questions could include:
“What are some important concerns that you may have?”
“Could you describe the most important of these concerns?”
“When did the difficulty first begin?”
“How often does it occur?”
“Have there been any changes in how often it has occurred?”
“What happens after the behavior(s) occurs?” (Groth-Marnat, 2003, p. 79-80).
Since clients vary in their personal characteristics (age, degree of cooperation, educational level, etc.) and type of problem (childhood difficulties, legal problems, psychological problems), the questions should vary from person to person (Groth-Marnat, 2003). In Cindy’s case, the above questions are appropriate to ask. The series of questions should not be rigid, but asked with a certain level of flexibility, in order to explore relevant but unique issues that may arise during the interview. It is difficult to speculate on the conduction and outcome of the interview, because different theoretical perspectives will exist when it comes to clinician-client interaction between Dr. Goldstein and Cindy. It is important to note, that, a successful interview is achieved first and foremost with a proper attitude of the clinician, and not so much by what he or she says or does. The interviewer should always express “sincerity, acceptance, understanding, genuine interest, warmth, and a positive regard for the worth of the person. If clinicians do not demonstrate these qualities, they are unlikely to achieve the goals of the interview, no matter how these are defined” (Groth-Marnat, 2003, p. 80).
Dr. Goldstein should be aware of the interviewer effect because his interview with Cindy is a social interaction and his appearance may influence her answers. This is a common problem and such bias can render the results of the study invalid. For example, body language, age, gender, ethnicity, or social status of the interviewer can create this effect. If Dr. Goldstein happens to be of the same age and ethnicity of Cindy’s ex-husband, with a similar social status and body language, she may not answer all the questions without bias. Unfortunately, there is always going to be such a possibility when conducting an interview.
After Dr. Goldstein has concluded the interview with Cindy, he will then provide an outline of the behavioral assessment, similar to the behavioral interview. He will initially provide Cindy with an overview of what has to be accomplished with a clearly detailed specification of her problem behavior. Dr. Goldstein will identify the target behavior(s) and define them in exact behavioral terms. For example, Cindy’s target behaviors may be excessive worry and inability to relax as part of an anxiety disorder. The clinician will then determine the problem frequency, duration, and intensity (“How many times has the feeling of “going crazy” occurred today,” “How long did it persist”, etc.). He will then identify the conditions in which the problems (worrying, not being able to relax, and so on) occur “in terms of its antecedents, behaviors, and consequences” (Groth-Marnat, 2003, p. 114).
Dr. Goldstein will determine the desired level of Cindy’s performance and consider an estimate of how realistic this is for her with possible deadlines. He will definitely identify Cindy’s strengths and also suggest procedures for measuring her relevant behaviors. He will decipher who will record what and how will it be recorded, when and where. Then, Dr. Goldstein will determine how the effectiveness of the program should be evaluated. After completing the discussion of areas, he will summarize it to ensure that Cindy understands and agrees. Again, this outline should not be rigid and should be used as a general guideline (Groth-Marnat, 2003).
In Cindy’s case, the behavioral interview itself may have presented enough material for an adequate assessment but some form of actual behavioral observation may be required before, during, and after treatment. A method for observing the behavior(s) is often decided on during the initial behavioral interview. While interviews primarily serve to obtain verbal information from clients, behavioral observation conducted to actually carry out certain techniques and strategies of measuring relevant areas of behavior that were previously discussed during the behavioral interview. With Cindy, a behavioral observation may be useful, although it is usually used more frequently in cases such as assessing young children, the developmentally disabled, or resistant clients, but it would be interesting to obtain interval recording, narrative recording, ratings recording, and event recording. Dr. Goldstein may ask Cindy to observe her relevant target behaviors. He and Cindy will have to decide on the number of target behaviors to record and the complexity of a recording method, as the task will have to remain manageable and not “overly complex” (Groth-Marnat, 2003).
Target behavior(s) should be identified in a narrative description of Cindy’s problems and later specified by determining the antecedents and consequences related to her problem behavior. All of her behaviors need to be measured in an objective manner, with complete definitions that enable concise observations of the measures of the behaviors. Such definitions should not include abstract terms, such as absentmindedness or sadness, and instead concentrate on specific behaviors. Furthermore, the definitions should be easy to read. When Dr. Goldstein is measuring behavioral frequencies, he must clearly define when the behaviors begin and end. It can be difficult to measure less clearly defined behaviors. The recordings should measure the duration of behaviors and their intensity. For example, how fast does Cindy’s heart beat during an anxiety/panic attack in which she feels that she is losing her mind and how long did this heart rate remain? Measurements as such will determine how urgent and strong a treatment approach should be (Groth-Marnat, 2003).
Of further importance is the setting of a behavioral observation and it can range from a natural setting to a highly structured one. Natural, or in vivo, settings for Cindy can include her home, the park, or the mall. Such natural settings are the most effective ones when trying to assess high-frequency or depressive behaviors, as in Cindy’s case. Unfortunately, observations in natural settings require an extensive amount of time but are useful when the amount of change the client has made is measured after a treatment. Dr. Goldstein may decide to create a structured environment, such as a role play, that bring out specific types of behaviors. Such environments can be important for infrequent behaviors but this type of setting may not generalize into Cindy’s actual life. The training of the observer has to include a clear understanding of measuring the behaviors, emphasizing on taking objective and accurate recordings. The clinician should take precautions to avoid observer error, through bias, lapses in concentration, leniency, and discussing of data with other observers. Reliability may be checked by “comparing the degree of agreement between different observers rating the same behaviors” (Groth-Marnat, 2003, p.116). After gathering enough information about their clients’ history and pertinent data during behavioral interviews and assessments, clinicians have a clear picture of each case and will be able to design and implement the correct treatment plan.
Groth-Marnat, Gary (2003). Handbook of Psychological Assessment 4th ed. John Wiley & Sons.
Retrieved on 20 February 2015 from http://marijag.home.mruni.eu/wp-content/uploads/2009/02/handbook-of-psychological-assessment-fourth-edition.pdf.
Steege, M.W., & Watson, T.S. (2013). Conducting School-Based Functional Behavioral Assessments, Second Edition. Guilford Press. VitalBook file.